Client Forms

If you are interested in the counseling services of Ellis Counseling, please take a moment to download and fill out our new client intake form. We also have copies available at our clinic; however, filling out the form beforehand will save time at your first visit.

Insurance Questions and coverage
Authorization to Release Records
Informed Consent for Teletherapy Services

Adult Forms

HIPPA Privacy Notice for Ellis Counseling, LLC March 09
Info on Patients Rights for HIPPA with Signature of Notice
Ellis Counseling Intake Form
Ellis Counseling Informed Consent
Consent to file insurance

Child and Adolescent Forms

HIPPA Privacy Notice for Ellis Counseling, LLC March 09
Info on Patients Rights for HIPPA with Signature of Notice
AUTHORIZATION FOR COUNSELING SERVICES for minors
Ellis Counseling Child-Adolescent Intake Form
Ellis Counseling Informed Consent
Adolescent Informed Consent Form (Ages 14 and above)
Consent to file insurance

Couples Forms

HIPPA Privacy Notice for Ellis Counseling, LLC March 09
Info on Patients Rights for HIPPA with Signature of Notice
Ellis Counseling Intake Form
Ellis Counseling Informed Consent
Couple Informed Consent
Consent to file insurance

Good Faith Estimate Requirement
Under Section 2799B of the Public Health Service Act, health care providers and health care facilities are required to provide a good faith estimate of expected charges for items and services to individuals who are not enrolled in an insurance plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage.  The Good Faith Estimate for Health Care Items indicates you are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy service provided to you.